Written by

Walter F. Roche Jr.

The Tennessean

Alice Hazelwood, diagnosed with dementia after suffering a stroke, underwent a four-year journey through nursing homes before her death. / Submitted

What are antipsychotic medications?

Antipsychotic medications belong to a broad category of psychopharmacologic medications and are designed to affect mood, mental function or behavior. They are approved by the FDA for treatment of schizophrenia and bipolar disorder in adults, among other conditions. How can a nursing home patient with dementia be prescribed a drug to treat schizophrenia if all he or she has is dementia?Physicians are free to prescribe any prescription medication, including antipsychotics, for uses that go beyond the ones officially approved by the FDA. This is referred to as “off-label” and is quite common. Antipsychotics are frequently used to treat symptoms of psychosis, which involve hallucinations or delusions, including paranoia. What are some common behavior symptoms in dementia patients?Agitated behavior, such as disruptive physical or vocal behavior. This could include cursing, verbal aggression, hitting, grabbing, tearing things, pushing, biting, spitting, hiding or hoarding. What are some non-pharmacologic approaches to management of dementia symptoms?A first step is to try to identify an underlying cause. The explanation may be a physical problem, such as a toothache or fecal impaction in a demented person who is unable to communicate verbally. Development of a behavioral intervention might involve fixing a physical problem or removing a trigger. For example, a female resident who becomes agitated when a male nurse assists her with dressing. Or a resident who becomes agitated when left sitting alone. Music has been shown to reduce agitation. And environment can alleviate some symptoms — so attention to colors, lighting, noise levels and temperature is important. Source: Excerpted and paraphrased from American Society of Consultant Pharmacists, March 2012 report “The Use of Antipsychotic Medications in Nursing Home Residents”

DEMENTIA
takes its toll

These photos show the progression of dementia in Alice Hazelwood, / Submitted photos

These photos show the progression of dementia in Alice Hazelwood, / Submitted

Westmoreland Care & Rehabilitation Center resident Tommie Wilbron, 83, works in the center's 'Country Store' which was created to give residents purpose. The space was once an office. / Shelley Mays / The Tennessean

Dr. G. Allen Power talks during a training session for nursing home workers on how to handle dementia patients without resorting to psychotropic drugs. Dr. Power's book 'Dementia Beyond Drugs: Changing the Culture of Care' was released in 2010. / Larry McCormack / The Tennessean

Dementia Vincent Davis listens as G. Allen Power talks during a training session for nursing home workers on how to handle dementia patients without resorting to psychotropic drugs. / Larry McCormack / The Tennessean

Dementia Vincent Davis listens as G. Allen Power talks during a training session for nursing home workers on how to handle dementia patients without resorting to psychotropic drugs. / Larry McCormack / The Tennessean

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Alice Hazelwood’s two daughters say they pleaded with nursing home staff to take their 84-year-old mother off the “head meds” that left her dazed and zombie-like.

“It was so bad,” said Patricia Shane of Chapmansboro, “that she couldn’t move. She was catatonic.”

One day, Kathleen Crouch, Shane’s sister, found her mother in the lunchroom with her head down in her dish.

“Her eyes were glazed over like a dead man,” she said. Her mother would be given a Dixie cup full of pills at a time, “shut-up pills.”

When the nursing home staff finally did stop one of the drugs, Shane and Crouch of Nashville say, it was too late. Hazelwood, who was diagnosed with dementia after a stroke, died March 6.

Alice Hazelwood’s pill-laden four-year journey through nursing homes may not be unusual. State health officials say the overuse of antipsychotic drugs in Tennessee nursing homes, particularly on those diagnosed with dementia, is a huge problem.

About 30 percent of long-term nursing home residents in Tennessee are being treated with antipsychotics, according to statistics collected by the Centers for Medicare and Medicaid Services. The national average is 23.8 percent, which federal officials want cut by 15 percent by year-end. Tennessee’s rate is highest in the Southeast.

Health officials believe that too many patients with dementia are being given antipsychotics in an “off-label” use to control behavior instead of treating their dementia symptoms through non-pharmacologic therapy. Prescribing antipsychotics — approved by the FDA to treat schizophrenia and bipolar disorder among conditions — can expose a patient to medical risks.

Though exact figures on how many nursing home residents have dementia are not available, experts say the average is 65 to 70 percent per facility.

The state, with a $370,000 grant from the Centers for Medicare and Medicaid Services, has initiated a series of training sessions for nursing home workers on ways to treat patients without resorting to pills, especially antipsychotics.

The FDA requires that the packaging on those drugs contain a “black box warning” that administering them to elderly dementia patients increases the chance of death and can have other harmful side effects.

Understand the patient

Vincent Davis, state health care facilities director, said the ultimate goal of the drug use reduction campaign is to improve patients’ overall well-being.

“We need to try to understand what the person is trying to express,” Davis added, rather than just giving out a pill.

He noted the overuse of antipsychotic drugs is not limited to nursing home patients. It is a problem in assisted living and also in foreign countries.

Angie McAlister from the 100-bed Westmoreland Care and Rehabilitation Center in Westmoreland was one of those attending a recent training session at the Scarritt-Bennett Center in Nashville and said an effort to cut down the use of antipsychotic drugs is already in place at her facility.

“We try to treat each patient as an individual. It’s all about stopping and slowing down,” she said, adding that the care must be “person-directed.”

Shawn O’Conner, CEO at the facility, said 75 percent of the residents at Westmoreland have some form of dementia. He said efforts this year reduced the number of patients on antipsychotic drugs from 43 percent to 29 percent.

The federal government has been able to pinpoint the problem in nursing homes because it is paying for many of the drugs through the Medicare program.

Data for nursing homes in nine mid-Tennessee counties show that most far exceed the national average in the percentage of long-term patients treated with antipsychotic drugs. The highest rate, 46.5 percent, was at Crestview Health and Rehabilitation in Nashville. The lowest, 9 percent, was at Vanco Manor in Goodlettsville.

Davis said the nursing homes submit the raw data, which the Centers for Medicare and Medicaid Services processes to come up with usage rates.

Jay Moore of the Tennessee Health Care Association, which represents nursing homes, said the group supports reducing the use of antipsychotic drugs.

“While we might not be able to completely eliminate the use of such medications, the goal is really to reduce the usage. Caregivers really have to look at the circumstances on a case-by-case basis to determine proper medication administration,” Moore said.

Find underlying cause

The first of the state training sessions was held last week in Nashville. It was led by Dr. G. Allen Power, a mentor with The Eden Alternative, which is conducting the training sessions.

Power, who has written a book on treating dementia patients without drugs, said the goal of the sessions is to change how nursing home caregivers look at dementia patients. They need to focus on positive attributes and not deficits.

Dispensing pills, he said, is an effort to treat symptoms, such as acting out, without trying to find the underlying cause.

“When the front door is broken, you try the back door or a side door,” Power said, adding that making a personal connection to the patient is key.

Carol Mace, also with the state Division of Health Care Facilities, said patients on antipsychotics are more likely to fall, and when alarms are placed on them they become afraid to move.

That inactivity makes them more likely to deteriorate. Taking people off psychotropics, she said, reduces fall risks.

At the training session, the attendees, including some state nursing home inspectors, were asked to come up with strategies to change the environment in nursing homes to focus on the patients, without adding costs.

One group suggested recipe sessions with patients in the hopes the subject would bring back pleasant memories and make a connection to the past.

Another group produced two lists: one with no anticipated costs and the other with “just a little more money.”

Molly Findley, the director of nursing at Spring City Health Care and Rehabilitation, told of a patient at her home who had suffered a stroke and hadn’t spoken a word in two years.

Findley had handed her a toy one day and saw that the patient began to twirl it in her hand.

“It made me think of a baton twirler. Maybe she had been one,” Finley said.

A colleague at Spring City brought in a baton a few days later, and the patient began to twirl. Findley and staffers got the patient to put on a performance for the other patients.

About a week later the patient was talking.

The toy and the baton, Findley said, had made a connection.

But for Kathleen Crouch and Patricia Shane, there was no happy ending. The sisters noted that their mother wasn’t the only nursing home resident who was heavily medicated.

“Those patients were sitting there in zombie land,” Crouch said.

“We just want to keep someone else from having to go through what we did,” Shane said.